Evaluating resident involvement and the 'July effect' in parotidectomy.

OBJECTIVE: This study aimed to evaluate the effect of resident involvement and the 'July effect' on peri-operative complications after parotidectomy. METHOD: The American College of Surgeons National Surgical Quality Improvement Program database was queried for parotidectomy procedures with resident involvement between 2005 and 2014. RESULTS: There were 11 733 cases were identified, of which 932 involved resident participation (7.9 per cent). Resident involvement resulted in a significantly lower reoperation rate (adjusted odds ratio, 0.18; 95 per cent confidence interval, 0.05-0.73; p = 0.02) and readmission rate (adjusted odds ratios 0.30; 95 per cent confidence interval, 0.11-0.80; p = 0.02). However, resident involvement was associated with a mean 24 minutes longer adjusted operative time and 23.5 per cent longer adjusted total hospital length of stay (respective p < 0.01). No significant difference in surgical or medical complication rates or mortality was found when comparing cases among academic quarters. CONCLUSION: Resident participation is associated with significantly decreased reoperation and readmission rates as well as longer mean operative times and total length of stay. Resident transitions during July are not associated with increased risk of adverse peri-operative outcomes after parotidectomy.

Supervised Autonomous Electrosurgery via Biocompatible Near-Infrared Tissue Tracking Techniques.

Autonomous robotic surgery systems aim to improve patient outcomes by leveraging the repeatability and consistency of automation and also reducing human induced errors. However, intraoperative autonomous soft tissue tracking and robot control still remains a challenge due to the lack of structure, and high deformability of such tissues. In this paper, we take advantage of biocompatible Near-Infrared (NIR) marking methods and develop a supervised autonomous 3D path planning, filtering, and control strategy for our Smart Tissue Autonomous Robot (STAR) to enable precise and consistent incisions on complex 3D soft tissues. Our experimental results on cadaver porcine tongue samples indicate that the proposed strategy reduces surface incision error and depth incision error by 40.03% and 51.5%, respectively, compared to a teleoperation strategy via da Vinci. Furthermore, compared to an autonomous path planning method with linear interpolation between the NIR markers, the proposed strategy reduces the incision depth error by 48.58% by taking advantage of 3D tissue surface information.

Utility of current sialendoscopes in the sinonasal cavity.

OBJECTIVES: This study assessed the utility of current sialendoscopes in the paranasal sinuses in a cadaveric model and evaluated novel uses for sialendoscopes. METHODS: Currently available sialendoscopes were used for visualisation and performing interventions in the paranasal sinuses. Ten cadaver heads were studied before and after dissection. Outcomes included ostia identification, sinus cannulation, success of mucosal biopsy collection and image clarity. RESULTS: Marchal and Erlangen sialendoscopes were found to be effective for both visualising and cannulating the sphenoid sinuses before and after dissection. Both types demonstrated poor maxillary ostia visualisation without dissection, but did allow treatment after antrostomy. Larger diameter sialendoscopes were associated with the lowest image distortion during maxillary ostia assessment. Mucosal biopsy collection within the sphenoid sinus, but not in the maxillary sinus, was possible before dissection. CONCLUSION: Sialendoscopes can be used for visualisation and performing interventions in the sinonasal cavity, but their utility is mainly limited to the sphenoid sinus. They may be considered a minimally invasive method for drug delivery and/or biopsy collection in the post-operative setting for all sinuses. Design improvements are suggested.

Prevalence of nonalcoholic fatty liver disease in patients with type 2 diabetes mellitus.

OBJECTIVES: Nonalcoholic fatty liver disease (NAFLD) is commonly associated with type 2 diabetes mellitus (DM) though its prevalence is not well studied. We conducted a prospective study of prevalence and risk factors of NAFLD in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: 204 type 2 DM patients attending an out-patient diabetic clinic underwent abdominal sonography. Ninty of 127 patients with fatty infiltration on ultrasound consented for liver biopsy, clinical and biochemical workup. RESULTS: Eighty seven percent had NAFLD on histology with 62.6% steatohepatitis and 37.3% fibrosis. Age, duration of diabetes mellitus, degree of glycemic control, body mass index, waist circumference, family history of diabetes mellitus, did not predict the presence or severity of NAFLD or fibrosis. Serum alanine aminostranferase (ALT) and alkaline phosphatase levels, though within normal limits, were significantly higher in patients with steatohepatitis. Prevalence of NASH increased with increase in the components of the metabolic syndrome. Serum AST/ALT ratio were also significantly higher (p-0.049) in patients with severe fibrosis. All patients with severe fibrosis had metabolic syndrome. CONCLUSIONS: Prevalence of NAFLD and NASH in our cohort of type 2 DM patients is high and increases with multiple components of metabolic syndrome. NASH and advanced fibrosis can occur in diabetic patients without any symptoms, signs or routine laboratory test abnormalities.

Electroconvulsive therapy in drug resistant neuroleptic malignant syndrome.

We report a case of a 20 years female referred to us with a history of a brief psychotic episode for which she was given inj. Haloperidol. The patient presented in an unconscious state with high grade fever. The diagnosis was kept as neuroleptic malignant syndrome after ruling out other possibilities. The patient did not respond to Bromocriptine and Dantrolene. With the recent evidence of electroconvulsive therapy being useful in these patients, we went ahead with the same. We present this case to share our experience of the excellent response of neuroleptic malignant syndrome to electroconvulsive therapy.

Semi-automated imaging system to quantitate estrogen and progesterone receptor immunoreactivity in human breast cancer.

A semi-automated imaging system is described to quantitate estrogen and progesterone receptor immunoreactivity in human breast cancer. The system works for any conventional method of image acquisition using microscopic slides that have been processed for immunohistochemical analysis of the estrogen receptor and progesterone receptor. Estrogen receptor and progesterone receptor immunohistochemical staining produce colorimetric differences in nuclear staining that conventionally have been interpreted manually by pathologists and expressed as percentage of positive tumoral nuclei. The estrogen receptor and progesterone receptor status of human breast cancer represent important prognostic and predictive markers of human breast cancer that dictate therapeutic decisions but their subjective interpretation result in interobserver, intraobserver and fatigue variability. Subjective measurements are traditionally limited to a determination of percentage of tumoral nuclei that show positive immunoreactivity. To address these limitations, imaging algorithms utilizing both colorimetric (RGB) as well as intensity (gray scale) determinations were used to analyze pixels of the acquired image. Image acquisition utilized either scanner or microscope with attached digital or analogue camera capable of producing images with a resolution of 20 pixels /10 mu. Areas of each image were screened and the area of interest richest in tumour cells manually selected for image processing. Images were processed initially by JPG conversion of SVS scanned virtual slides or direct JPG photomicrograph capture. Following image acquisition, images were screened for quality, enhanced and processed. The algorithm-based values for estrogen receptor and progesterone receptor percentage nuclear positivity both strongly correlated with the subjective measurements (intraclass correlation: 0.77; 95% confidence interval: 0.59, 0.95) yet exhibited no interobserver, intraobserver or fatigue variability. In addition the algorithms provided measurements of nuclear estrogen receptor and progesterone receptor staining intensity (mean, mode and median staining intensity of positive staining nuclei), parameters that subjective review could not assess. Other semi-automated image analysis systems have been used to measure estrogen receptor and progesterone receptor immunoreactivity but these either have required proprietary hardware or have been based on luminosity differences alone. By contrast our algorithms were independent of proprietary hardware and were based on not just luminosity and colour but also many other imaging features including epithelial pattern recognition and nuclear morphology. These features provide a more accurate, versatile and robust imaging analysis platform that can be fully automated in the near future. Because of all these properties, our semi-automated imaging system 'adds value' as a means of measuring these important nuclear biomarkers of human breast cancer.

Utilization of antihepatocyte clone OCH1E5 (Hep Par 1) in histological evaluation of liver tumors.

Diagnosis of hepatocellular carcinoma (HCC) is not always easy on simple hematoxylin and eosin (H&E) stain. The diagnostic problems arise when tumor shows pseudoglandular, pleomorphic or clear cell differentiation. Various tumors markers have been described with varying sensitivity and specificity. Monoclonal antibody Hep Par 1 (OCH1E5) which is specific for hepatocytes offers great help in separation of these tumors. The aim of the present study was to determine utility of Hep Par 1 (OCH1E5) in differentiating HCC from metastatic tumors and cholangiocarcinoma. Total of 62 cases of liver tumors obtained from biopsies, resected or autopsy specimens were included in the study. Slides having representative sections were subjected to immunohistochemistry with monoclonal antibody Hep Par 1 (Dako Corp) using avidin biotin technique with primary antibody dilution of 1:40. Adjacent nontumorous hepatocytes were taken as positive control. Slides were examined by experienced pathologist without any information of clinical or H&E diagnosis. Cases were considered positive for Hep Par 1 if tumor cells showed cytoplasmic brown colored granules. The intensity and distribution (diffuse/ focal) of immunoreactivity was noted. Subsequently immunohistochemistry results were correlated with histology and clinical diagnosis. Hep Par 1 antibody was positive in 26 (42 %) and negative in 36 (58 %) liver tumors. On correlating with H&E sections, out of 26 positive cases, 25 (89.2%) were HCC and one was the case of metastasis of mucin secreting adenocarcinoma. From 36 tumors with negative staining 3 were cases of HCC, 27 metastatic adenocarcinomas and 6 cholangiocarcinomas. Only one case of liver metastasis of mucin secreting adenocarcinoma showed positivity. None of the cases of cholangiocarcinoma showed positivity for Hep Par 1. The three HCCs which did not take up staining for Hep Par 1 were 2 cases of moderately differentiated HCC having pseudoglandular pattern and a case of well differentiated HCC with trabecular arrangement. In 11(44%) cases staining was diffuse while in 14 (56%) it was focal but intense. Hep Par 1 is a useful marker in differentiating HCC from metastaic tumors and cholangiocarcinoma with sensitivity and specificity of 89 % and 97 % respectively and positive predictive value of 96 %. However one should be aware of limitations of immunohistochemistry.

Clinico-pathological follow-up after total colectomy and straight ileo-anal anastomosis done for ulcerative colitis.

BACKGROUND: Restorative proctocolectomy is used as surgical treatment for ulcerative colitis. We have earlier documented adaptative changes in the terminal ileum after total colectomy, and straight ileo-anal anastomosis. AIM: To correlate the morphologic and functional changes in the ileal mucosa after total colectomy and hand-sewn straight ileo-anal anastomosis for ulcerative colitis. METHODS: Thirty consecutive patients (age range 15-50 years, 24 men) who had undergone total colectomy, rectal mucosectomy and hand-sewn straight ileo-anal anastomosis for ulcerative colitis were included in the study. These patients were followed up at 3-monthly intervals following surgery for two years and later once every year for a median duration of 9.5 (range 1-17) years. The clinical parameters studied were weight gain, frequency of stools, nature of stools, nocturnal stool frequency and need for antidiarrheal drugs. At each follow-up visit they were subjected to per rectal ileoscopy with ileal biopsy and barium enema. Ileal biopsy was analyzed histologically and histochemically. RESULTS: The clinical features improved over time, with average weight gain of 5 (range 1-7) Kg at one year. Frequency of stools decreased from 8-10 per day to 2-3 per day. The stools became semisolid and there was no need for antidiarrheal drug by the end of one year. All the patients showed adaptative changes in the ileum. The ileal mucosa was completely transformed into colonic type by the end of one year, colonoscopically (spacious lumen characteristic of colon), radiologically (disappearance of ileal characteristics with rectosigmoid-like appearance), histologically (blunting of villi with increase in goblet cells), and histochemically (sialomucin pattern to sulfomucin pattern). CONCLUSIONS: The ileum undergoes adaptative changes with corresponding improvement of clinical parameters over time, after proctocolectomy and ileoanal anastomosis for ulcerative colitis.

Nonfunctioning islet cell tumor presenting with ascites and portal hypertension.

Nonfunctioning islet cell tumors commonly cause no symptoms. A 22-year-old woman presented with lump in the left hypochondrium, refractory high-protein ascites and evidence of left-sided portal hypertension. At exploratory laparotomy, a 30 cm x 15 cm mass was seen at the splenic hilum, with large collateral vessels around. Distal pancreatectomy with splenectomy was done. Histology of the mass showed malignant islet cell tumor infiltrating the spleen. The patient died in the postoperative period.

Elimination pathways of [14C]losoxantrone in four cancer patients.

Losoxantrone is an anthrapyrazole derivative in Phase III development in the U.S. for solid tumors, notably breast cancer. To obtain information on the routes of elimination of the drug, a study was conducted in four patients with advanced solid tumors, which involved intravenous administration of 100 microCi of [14C]losoxantrone for a total dose of 50 mg/m(2) during the first course of losoxantrone therapy. Blood, urine, and feces were collected for up to 2 weeks and were analyzed for total radioactivity and parent drug. In addition, feces were profiled for the presence of metabolites. Plasma concentrations of total radioactivity exhibited a temporal pattern similar to the parent drug. Combined recovery of administered total radioactivity from urine and feces was 70% with the majority (87%) of this radioactivity excreted in the feces, presumably via biliary excretion. Feces extracts were profiled for metabolites using a high-performance liquid chromatography method developed to separate synthetic standards of previously identified human urinary metabolites. Only intact losoxantrone was found in the feces. About 9% of the dose was excreted in the urine, primarily during the first 24 h and mostly in the form of parent compound. Collectively, these data indicate that fecal excretion of unmetabolized drug via biliary and/or intestinal excretion is the primary pathway of intravenously administered losoxantrone elimination in cancer patients with refractory solid tumors.

Acquisition of Helicobacter pylori infection and reinfection after its eradication are uncommon in Indian adults.

BACKGROUND: Eradication of Helicobacter pylori infection is known to decrease the recurrence rate of peptic ulcer disease. Data from India on the acquisition rate of H. pylori infection and reinfection after eradication are scant. AIM: To study the rates of acquisition of H. pylori infection and of reinfection after eradication in Indian adult patients. METHODS: We evaluated 116 consecutive patients with dyspepsia undergoing endoscopy. Sixty-four of them were H. pylori-positive on gastric antral biopsy (rapid urease test and histology). Patients diagnosed to have H. pylori infection were treated with a four-drug regimen (omeprazole, bismuth subcitrate, tetracycline, furazolidine) for 2 weeks; those failing H. pylori eradication were treated with a second regimen (lansoprazole, amoxycillin, secnidazole) for one week. Patients who were H. pylori-negative to begin with and those who had successful H. pylori eradication were followed up clinically and endoscopically every 3 months for a median of one year. RESULTS: Ninety-six patients (50 H. pylori-positive) were available for study; the other 20 were lost to follow up after the first endoscopy. Fifty of the 96 (52%) were H. pylori-positive; four of these 50 patients did not follow up after first treatment. The eradication rate with the four-drug regimen was 89.1% (41/46). Four of the 5 non-responders eradicated H. pylori with the second regimen. At the end of median one year follow-up (range 9-15 months), one of the 45 patients (2.4%) who eradicated the organism developed reinfection; none of the 46 patients who were initially H. pylori-negative acquired new infection. CONCLUSIONS: The risk of reinfection after eradication is low in Indian subjects at the end of one year. The rate of acquisition of new infection is also low in the adult population.

Hepatic sickling crisis mimicking recurrent cholangitis.

A 22-year-old man with homozygous sickle cell disease presented with recurrent fever, right upper quadrant pain and jaundice. Liver biopsy confirmed the diagnosis of hepatic sickling crisis; the symptoms responded to hydroxyurea therapy. Hepatic vasocclusive crisis can diagnosed on liver biopsy, and need not be a diagnosis of exclusion.

Mesenteric vasculopathy in intestinal tuberculosis.

BACKGROUND: Involvement of mesenteric vessels in intestinal tuberculosis and its role in the pathogenesis of the intestinal changes have not been studied histologically. AIM: To study mesenteric vessels in patients undergoing surgery for complications of intestinal tuberculosis. METHODS: Resected intestinal specimens from 68 patients presenting with intestinal perforation and intestinal obstruction were examined; involvement of the major mesenteric vessels was evaluated. RESULTS: Granulomas were seen in the vessel wall in one case and near the vessel wall in 11 cases, intraluminal thrombi were seen in 23 cases, and subintimal fibrosis in nine cases. Perivascular cuffing was seen in intramural and subserosal vessels in ten cases. CONCLUSIONS: Changes in the vessel wall may lead to gut ischemia, which may contribute to the development of strictures and stercoral perforation in intestinal tuberculosis.

Effect of drying conditions on the taxane content of the needles of ornamental Taxus.

The effect of drying intact clippings of Taxus on the recovery of taxol and related compounds was studied under different drying conditions which included tobacco drying barn, greenhouse, shadehouse, air conditioned laboratory, oven, and freeze-drying. For clippings dried under tobacco barn, greenhouse, oven, and freeze-drying conditions, nearly total recovery of the expected levels based upon projections from analysis of fresh biomass was observed for taxol and cephalomannine. However, only 75-80% of the expected values for 10-deacetyltaxol and 10-deacetylbaccatin III were found. When the length of drying was extended up to 10 and 15 days as in the shadehouse and laboratory conditions, the recovery of all taxanes was adversely affected.

Phase I safety and pharmacokinetic studies of brequinar sodium after single ascending oral doses in stable renal, hepatic, and cardiac allograft recipients.

Brequinar sodium (BQR), a substituted 4-quinoline carboxylic acid, was in clinical development in combination with cyclosporine (CsA) as a potentially effective therapy for the treatment and prophylaxis of rejection in organ transplant patients. This phase I study was performed in stable renal, hepatic, and cardiac transplant patients receiving CsA and prednisone maintenance therapy for immunosuppression. The pharmacokinetic objectives of this study were to characterize the pharmacokinetics of (a) single oral 0.5- to 4-mg/kg doses of BQR when given in combination with CsA and prednisone to stable renal, hepatic, and cardiac transplant patients and (b) steady-state oral doses of CsA, with and without single oral doses of BQR. In all three patient populations, the pharmacokinetics of BQR were characterized by a lower oral clearance (12-19 mL/min) than that seen in previous studies in patients with cancer (approximately 30 mL/min at similar doses) and a long terminal half life (13-18 hrs). This slower oral clearance for BQR could be due either to a drug interaction between BQR and CsA or to altered clearance or metabolic processes in patients with transplants. Steady-state CsA trough levels and the oral clearance of CsA were not affected by BQR coadministration. Among the three transplant populations, the cardiac transplant patients had lower oral clearance values of BQR and of CsA. The cause of this lower clearance is not known. Safety results indicate that BQR was well tolerated by this patient population.

Bleeding ileal schwannoma.

We report a case of ileal schwannoma who presented with bleeding per rectum. Three-vessel angiogram was the only diagnostic investigation, and revealed tumor blush in the mid-ileal region. On exploration, an intraluminal mass was found in the mid-ileal region along with a feeding vessel in the mesentery. Resection of the involved ileum with end-to-end anastomosis was done. Histopathology showed benign schwannoma of ileum involving the submucosa, muscularis propria and serosa.

Non-specific granulomatous inflammatory lesions of small bowel.

The entity of nonspecific granulomatous inflammatory lesions(NSGIL) of the small bowel is a diagnostic and therapeutic dilemma. Data of 52 histopathologically proven cases of NSGIL seen by us between 1986 and 1991 were analysed. All these patients presented with either intestinal obstruction or perforation. They were thoroughly evaluated and investigated for tuberculosis. Of the 52 patients, 6 patients received antitubercular therapy (ATT) before and after surgery and 32 patients only after surgery. Fourteen patients did not receive ATT. Surgical procedures undertaken included stricturoplasty, resection/anastomosis and simple suturing of perforation. No complications were seen in patients who received ATT; however, six of 14 patients who did not receive ATT developed wound sepsis and 2 developed partial wound dehiscence. Many of these NSGIL lesions could be tuberculous in etiology though typical caseating granulomas were not seen.